Surgery 1

Question 1

How can you differentiate between an incarcerated and strangulated inguinal hernia?

Answer 1

Incarcerated hernia
What’s happening?
herniated tissue becomes trapped and cannot be reduced back into place
- Pain but no systemic features
- bowel sounds present

Strangulated
What’s happening?
- Where the blood supply is interrupted
- tender, distended abdomen
- absent bowel sounds

Question 2

Talk through the Dukes Staging and there 5 year suruvalrates?

Answer 2

A Tumour confined to the mucosa 95%
B Tumour invading bowel wall 80%
C Lymph node metastases 65%
D Distant metastases 5% (20% if rescectable)

Question 3

Neonate hydroceles are they bad? general management?

Answer 3

Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life

Reassure its not sinister and will likely resolve within a year.

Question 4

Blood testing in thyroid disease

What do you test for in Hashimotos thyroiditis?

What do you test for in Graves?

What do you test for in medullary carcinoma of the thyroid?

What use is Thyroglobulin antibodies?

Answer 4

Hash= Anti TPO (thyroid perioxidase) hypo

Graves= Anti TSH rec antibodies (hyper)

Medularry carcinoma = Calcitonin. It is released by the parafollicular cells

Thyroglobulin antibodies- Not useful for clinically distinguishing between different types of thyroid disease, may be used as part of thyroid cancer follow up

Question 5

What is the strongest risk factor for developing anal cancer?

Other risk factors (6)

Answer 5

HPV infection

Others:
- HPV RFs- Anal intercourse, high lifetime number of sexual partners
- MSM
- HIV and those taking immunosuppressive medication for HIV
- Women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN)
- Immunosuppressive drugs used in transplant recipients
- Smoking

Question 6

Name a contrainidcation for Suxamethonium the muscle relaxer and why

Answer 6

contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Question 7

Complications of thyroid surgery

Electrolyte imbalance?
Presentation? 3
What ECG changes would you see? (2)

Answer 7

Hypocalcaemia

cramps and spasms, paraesthesia of the fingers, toes and peri-oral area.

ECG:
isolated QTc elongation
If very very bad then… isolated QTc elongation

Question 8

Nasopharyngeal carcinoma

STEM- what ethnicity has hgih risk?

Assoc with what virus + what tye of cancer is it?

When in STEM should you think of this diagnosis/ presentation? (5)

Imaging? (2)

First-line management?

Answer 8

STEM- Southern China

EBV and sqaumous cell

Presentation:
- UNILATERAL otalgia
- Unilateral nasal obstruction or epistaxis
- Unilateral serous otitis media
- Cranial nerve palsies e.g. III-VI
- Cervical lymphadenopathy

Combined CT and MRI

First-line- Radiotherapy

Question 9

Initial management of acute limb ischaemia? (4)
1. A-E
2.
3.
4.

Definitive management? (5)

Answer 9

• A-E
• analgesia- codeine + paracetamol
• IV unfractionated heparin
• vascular review
• intra-arterial thrombolysis
• surgical embolectomy
• angioplasty
• bypass surgery
• amputation: for patients with irreversible ischaemia

Question 10

Rectal bleeding- what is angiodysplasia?
Most common in what part of the bowel?

Answer 10

Arteriovenous lesion- cause bleeding which may be massive apart from that little symp

The right side of the colon is more commonly affected.

Question 11

In repair of AAA which artery can by affected and decrease in blood flow? What condition can it cause?

Answer 11

IMA- can cause ischaemic colitis

Question 12

Most common type of kidney cancer in adults?

Classic triad of symp?
+ Other symptoms? (2)

Answer 12

Renal cell carcinoma

• loin pain
• haematuria
• palpable abdo mass
• pyrexia of unknown origin, weight loss ect.

Question 13

Management of the acute phase of vestibular neuronitis?

Answer 13

short course of Prochlorperazine (conventional antipsychotic, stops the vomiting centre) - Should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms

Question 14

Management of sigmoid volvulus
Not ruptured =
- If unsuccessful?
Ruptured =

Answer 14

Not ruptured = Decompression via rigid sigmoidoscopy and flatus tube insertion
Second line- percutaneous colostomy tube to decompress the volvulus

Ruptured = Hartmann’s procedure

Question 15

Patient presents with RUQ pain and jaundice 3 weeks AFTER lapchole, whats the most common reason?

Answer 15

Gallstones may be present in the CBD causing ongoing jaundice and pain after cholecystectomy

Question 16

Just intubated someone and their sats start to drop fast! why?

Answer 16

oesophageal intubation

Capnography should also be present to confirm the correct siting.

Question 17

Fibroadenoma

Described as…
Increase risk of malig?
Mx

Answer 17

Described as…Mobile, firm, smooth breast lump - a ‘breast mouse’

Increase risk of malig?
no

Mx
- Will reduce over 2 years 30% get smaller
- Remove if > 3cm

Question 18

Breast cancer
Determinants for Masectomy over WLE? (4 including size)

Answer 18

DCIS > 4cm- Masectomy
- Large lesion, small breast
- Central tumour
- Multi focal tumour

Question 19

Breast cancer talk about when radiotherapy is offered, hormonal and chemo (whats given?) and biologics

Answer 19

Radio
- Everyone with WLE to reduce reoccurance up to 1/3
- Masectomy if T3 or T4 and 4 or more axillary lymph nodes

Hormonal
- ER +ve pre-menopausal = Tamoxifen (increases endometrial cancer, VTE and menopausal symp)
- ER +ve post-menopausal = Astronidozole

Chemo
- Given before to downstage a primary lesion or after if axially node disease.
Whats given? 5-fluorouracil, epirubicin and cyclophosphamide.

Bio
HER2 +ve- Trastuzumab
DONT USE IN Hx OF HEART DISORDERS

Question 20

Contraindications for laperoscopic surgeryn 4 absolutes!!

Answer 20

1. Raised ICP-pailloedema
2. Haem instability
3. Acute GI obstruction and dilated bowel loops >4cm
4. Uncorrected coagulopathy

Question 21

What do you see on ABX in chronic pancreatitis?

Answer 21

Calcification- look closely it looks quite stary

Alarm bells should be ringing with chronic alcohol Hx, abdo pain radiating to or including back pain and no particular pattern coming and going lasting several hours.

Question 22

Kid has splenectomy- what do you see on blood film 8 weeks later (2/4)

Answer 22

Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes

Question 23

Marjolin’s ulcer- what is it?

Answer 23

squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.

Question 24

diagnositc investigation/ imaging for aricose veins/chronic venous disease

Answer 24

Venous duplex ultrasound (NOT DOPPLER!!)

Duplex- just doppler plus an image of the veins structure

Question 25

initial management of acute limb ischaemia

give
1
2

Answer 25

1. IV morphine
2. IV heparin

Question 26

Acute limb ischaemia investigations

1. 1st line-
2. Next step…

Answer 26

1. 1st line- Doppler handeld
2. Next step… CT angiogram with contrast to assess extent

Question 26

Acute limb ischaemia investigations

1. 1st line-
2. Next step…

Answer 26

1. 1st line- Doppler handeld
2. Next step… CT angiogram with contrast to assess extent

Question 27

Superficial thrombophlebitis management
1.
2.
3. old school mod/mild-
4. old school severe

Answer 27

1. compression stockings (DO APBI FIRST TO CHECK ARTERIAL SUPPLY!)
2. LMWH (30 days) or Fondiparinux (45 days)
3. old school mod/mild- NSAID topical
4. old school severe - NSAID oral + PPI

Question 28

Always remember that diabetics have an increase in peripheral arterial calcification- therefore ABPI can be higher than expected